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Available from: Richard Lessells, Oct 07, 2015
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    • "Here we describe an HIV Treatment Failure Clinic (HIV-TFC) model developed for a primary health care programme in rural KwaZulu-Natal. We have reported clinical outcomes for adults on ART in this programme that are broadly similar to other public sector programmes in South Africa [11-13]. However, the programme’s systems for detection and management of ART failure have been relatively ineffective, to the extent that, of the 20 000 adults enrolled on ART by the end of 2010, fewer than 100 (0.5%) had been switched to second-line ART regimens despite virological failure rates comparable to other programmes in the region [14]. "
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    ABSTRACT: Antiretroviral drug resistance is becoming increasingly common with the expansion of human immunodeficiency virus (HIV) treatment programmes in high prevalence settings. Genotypic resistance testing could have benefit in guiding individual-level treatment decisions but successful models for delivering resistance testing in low- and middle-income countries have not been reported. An HIV Treatment Failure Clinic model was implemented within a large primary health care HIV treatment programme in northern KwaZulu-Natal, South Africa. Genotypic resistance testing was offered to adults (>=16 years) with virological failure on first-line antiretroviral therapy (one viral load >1000 copies/ml after at least 12 months on a standard first-line regimen). A genotypic resistance test report was generated with treatment recommendations from a specialist HIV clinician and sent to medical officers at the clinics who were responsible for patient management. A quantitative process evaluation was conducted to determine how the model was implemented and to provide feedback regarding barriers and challenges to delivery. A total of 508 specimens were submitted for genotyping between 8 April 2011 and 31 January 2013; in 438 cases (86.2%) a complete genotype report with recommendations from the specialist clinician was sent to the medical officer. The median turnaround time from specimen collection to receipt of final report was 18 days (interquartile range (IQR) 13-29). In 114 (26.0%) cases the recommended treatment differed from what would be given in the absence of drug resistance testing. In the majority of cases (n = 315, 71.9%), the subsequent treatment prescribed was in line with the recommendations of the report. Genotypic resistance testing was successfully implemented in this large primary health care HIV programme and the system functioned well enough for the results to influence clinical management decisions in real time. Further research will explore the impact and cost-effectiveness of different implementation models in different settings.
    BMC Health Services Research 03/2014; 14(1):116. DOI:10.1186/1472-6963-14-116 · 1.71 Impact Factor
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    • "Hlabisa sub-district located in the uMkhanyakude district in northern KwaZulu-Natal is predominately rural with a population of approximately 228 000. The Hlabisa HIV Treatment and Care Programme is a Department of Health (DoH) programme which has received operational support from the Wellcome Trust Africa Centre for Health and Population Sciences, (Africa Centre) and financial support from the Presidential Emergency Fund for AIDS Relief (PEPFAR) [27]. ( "
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    ABSTRACT: Patient satisfaction is a determinant of treatment uptake, adherence and retention, and an important health systems outcome. Queues, health worker-patient contact time, staff attitudes, and facility cleanliness may affect patient satisfaction. We quantified dimensions of patient satisfaction among HIV and TB patients in a rural sub-district of KwaZulu-Natal, South Africa, and identified underlying satisfaction factors that explained the data. We conducted patient-exit interviews with 300 HIV and 300 TB patients who were randomly selected using a two-stage cluster random sampling approach with primary sampling units (primary healthcare clinics) selected with probability-proportional-to-size sampling. We performed factor analysis to investigate underlying patient satisfaction factors. We compared the satisfaction with HIV and TB services and examined the relationships between patient satisfaction and patients' socio-demographic characteristics in multivariable regression. Almost all patients (95% HIV, 97% TB) reported to be globally satisfied with the healthcare services received on the day of the interview. However, patient satisfaction with specific concrete aspects of the health services was substantially lower: 52% of HIV and 40% of TB patients agreed that some staff did not treat patients with sufficient respect (p = 0.02 for difference between the two patient groups); 65% of HIV and 40% of TB patients agreed that health worker queues were too long (p < 0.001). Based on factor analysis, we identified five factors underlying the HIV data and the TB data (availability, accommodation, acceptability and communication for HIV and TB patients; health worker preference for HIV patients only; and global satisfaction for TB patients only). The level of satisfaction did not vary significantly with patients' socio-demographic characteristics. In this rural area, HIV and TB patients' evaluations of specific aspects of health services delivery revealed substantial dissatisfaction hidden in the global assessments of satisfaction. Patient A wide range of patient satisfaction variables could be reduced to a few underlying factors that align broadly with concepts previously identified in the literature as affecting access to healthcare. Increases in health systems resources for HIV and TB, but also improvements in facility maintenance, staff attitudes and communication, are likely to substantially improve HIV and TB patients' satisfaction with the care they receive in public-sector treatment programmes in rural communities in South Africa.
    BMC Health Services Research 01/2014; 14(1):32. DOI:10.1186/1472-6963-14-32 · 1.71 Impact Factor
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    • "The study was conducted in the predominantly rural Hlabisa health sub-district in northern KwaZulu-Natal, South Africa. The programme, delivered by the Department of Health with support from the Africa Centre for Health and Population Studies (, has been described previously [1,23,26]. HIV treatment and care is fully devolved to 17 primary health care (PHC) clinics and delivered largely by nurses and counsellors, with medical officers visiting clinics on a weekly or fortnightly basis. The programme adheres to national ART guidelines. "
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    ABSTRACT: Better understanding of drug resistance patterns in HIV-infected children on antiretroviral therapy (ART) is required to inform public health policies in high prevalence settings. The aim of this study was to characterise the acquired drug resistance in HIV-infected children failing first-line ART in a decentralised rural HIV programme. Plasma samples were collected from 101 paediatric patients (<=15 yrs of age) identified as failing ART. RNA was extracted from the plasma, reverse transcribed and a 1.3 kb region of the protease gene was amplified and sequenced using Sanger sequencing protocols. Sequences were edited in Geneius and drug resistance mutations were identified using the RegaDB and the Stanford, Rega and ANRS resistance algorithms. The prevalence and frequency of mutations were analysed together with selected clinical and demographic data in STATA v11. A total of 101 children were enrolled and 89 (88%) were successfully genotyped; 73 on a non-nucleoside reverse-transcriptase inhibitor (NNRTI)-based regimen and 16 on a protease inhibitor (PI)-based regimen at the time of genotyping. The majority of patients on an NNRTI regimen (80%) had both nucleoside reverse-transcriptase inhibitor (NRTI) and NNRTI resistance mutations. M184V and K103N were the most common mutations amongst children on NNRTI-based and K103N among children on PI-based regimens. 23% had one or more thymidine analogue mutation (TAM) and 6% had >=3 TAMs. Only one child on a PI-based regimen harboured a major PI resistance mutation. Whilst the patterns of resistance were largely predictable, the few complex resistance patterns seen with NNRTI-based regimens and the absence of major PI mutations in children failing PI-based regimens suggest the need for wider access to genotypic resistance testing in this setting.
    AIDS Research and Therapy 01/2014; 11(1):3. DOI:10.1186/1742-6405-11-3 · 1.46 Impact Factor
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